Research Article Evaluating of Life Quality in Patients with Acne Vulgaris Using Generic and Specific Questionnaires

Transcription

1 Dermatology Research and Practice Volume 2013, Article ID , 6 pages Research Article Evaluating of Life Quality in Patients with Acne Vulgaris Using Generic and Specific Questionnaires Reza Ghaderi, 1 Alireza Saadatjoo, 2 and Faezeh Ghaderi 3 1 Department of Dermatology, Birjand University of Medical Sciences, Ghaffari Street, Birjand , Iran 2 Faculty of Nursing, Birjand University of Medical Sciences, Ghaffari Street, Birjand , Iran 3 Department of Paediatric Dentistry, Shiraz University of Medical Sciences, Dental School, Ghasrodasht Street, Shiraz , Iran Correspondence should be addressed to Faezeh Ghaderi; ghaderi fa@sums.ac.ir Received 21 July 2013; Accepted 18 September 2013 Academic Editor: Craig G. Burkhart Copyright 2013 Reza Ghaderi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Acne vulgaris is a common skin disease that can adversely affect the quality of life of patients. Objective. Theaimof this study was to determine the quality of life in patients with acne vulgaris. Methods. This study was carried out on 70 patients with acne vulgaris (28 males, 42 females). All the patients filled out two Persian versions of questionnaires: short form 36 (SF-36) and Dermatology Life Quality Index (DLQI). The obtained data were analyzed by using SPSS software (version 17). Results.Thescores for physical functioning, social functioning, and bodily pain domains in patients were over 70%, but the scores for role physical, general health, vitality, role emotional, and mental health in patients were under 70%. Scores on the DLQI in patients with acne vulgaris ranged from 0 to 22 (mean ± SD, 8.18 ± 4.83). After comparing mean score of DLQI with respect to gender and age, it was found that the difference between the two groups was not statistically significant. Conclusion. Acne vulgaris has a significant effect on the quality of life. There was not any significant gender or age related difference in QOL. 1. Introduction Quality of life is a general term which includes a feeling of joy and satisfaction with life. Quality of life (QOL), self confidences,andselfesteeminpatientswithskindiseaseshavenot sufficiently been attended to. Since skin diseases affect wellbeing, general health, function, and social adaptation of the individual, they can decrease self confidence of the patient and definitely disrupt self image or cutaneous body image, mental health, and quality of his life [1, 2]. By even having chronic itching, life of a person will be charily disturbed [3]. Besides evaluating the treating procedure, recording QOL can advance our knowledge regarding psychosocial stress associated with dermatologic disorders [4]. According to the studies carried out in Canada [5], USA [6], Egypt [7], Denmark [8], Iran [9], UK [10], Turkey [11], Saudi Arabia [12], Brazil [13], and many other countries [14 19], skin diseases have a great effect on the QOL of patients. Patient s life would be influenced by acne vulgaris both physically and emotionally [15]. Psychological involvements include anxiety, depression, and those which deeply affect life s quality [16, 17]. The present study can declare the importance of psychological aspects to its readers to the extent that psychological consultation and intervention may be in regard to patients with acne vulgaris. Moreover, measuring the incapacities of patients with the aim of taking better care of them can be helpful in leading health-care services towards the real needs of the patients. Considering the above and the fact that according to WHO sprogramsoneofthedutiesofhealth-careofficialsis to promote the level of QOL, the present study was conducted to evaluate QOL in Iranian patients with acne vulgaris. 2. Methods This study was performed on 70 patients with acne vulgaris. Inclusion criteria include having acne vulgaris and being over the 16 years. Exclusion criteria include having skin diseases

2 2 Dermatology Research and Practice Table 1: Comparison of mean score of QOL (SF-36) in different domains with respect to gender using t-test. Domains Male (n = 28) Female (n = 42) Total Mean ± std. deviation Mean ± std. deviation Mean ± std. deviation P value PF ± ± ± RP ± ± ± RE ± ± ± VT ± ± ± MH ± ± ± SF ± ± ± BP ± ± ± GH ± ± ± Total ± ± ± Physical functioning (PF); role physical (RP); role emotional (RE); Vitality (VT); mental health (MH); social functioning (SF); bodily pain (BP); general health (GH). differentfromtheacnevulgaris,havingachronicdisease which would have an effect on QOL, or having apparent disability. The study was carried out in the dermatology outpatient clinic of Valiyy-e-asr hospital in Birjand, Iran, between May 2009 and May All those who had referred to the clinic had the entrance requisites for the study. The aims of the survey were explained to them. The responders gave their informed written consent to participate in the study. The institutional ethical committee approved the study protocol. Two Persian versions of questionnaires, DLQI (which is a specific questionnaire) and SF-36 which, is a generic one, were given to all those diagnosed with acne vulgaris by a dermatologist. DLQI questionnaire was designed by Finlay and Khan in1992,andsincethen,ithasvastlybeenusedindifferent communities [1, 7, 9 11, 13, 14, 16, 18]. Furthermore, reliability and validity of the Persian versionofthedlqiquestionnairehadbeenprovedthrougha study in a group of Iranian patients with vitiligo in Shiraz by Aghaei et al. [9].Reliabilityanalysisshowedsatisfactoryresult (Cronbach s alpha coefficient = 0.77) [9]. The questionnaire includes 10 multiple-choice questions; the points for each question range between 0 and 3. Total scoreofeveryindividual sqolwouldbethesumoftotal scores of all the questions, that is, between 0 and 30; the more anindividual sscore,theworsehisqol.thequestionnaire was divided into 6 parts: symptoms and feelings (questions 1 and 2), daily routine activities (questions 3 and 4), leisure and spare time (questions 5 and 6), individual relations (questions 8 and 9) occupation and school (question 7), and treatment (question 10) [10]. SF-36questionnaireisagenericonewhichhasvastly been used in different communities [12, 13, 19, 20, 31 35]. Furthermore, reliability and validity of the Persian version of SF-36 questionnaire had been proved through a study in Tehran by Montazeri et al. [33] and another study in Shiraz by Jafari et al. [34]. Reliability analysis showed satisfactory results (Cronbach s alpha coefficient = 0.915) [34]. It Comprises of 36 items assessing eight domains of life quality: Physical Functioning (PF); Role Physical (RP), which refers to role restrictions due to physical problems; Bodily Pain (BP); General Health(GH); Vitality (VT); Social Functioning (SF); Role Emotional (RE), which refers to role restrictions due to emotional problems; and Mental Health (MH) [12]. The achieved scores in each of the domains are separately summed up ranging from 0 to 100 ; the more an individual s score, the better his QOL. Data were analyzed by SPSS software (version 17). Students t-test, analysis of variance (ANOVA), Tukey ranged tests and Pearson s correlation coefficient test were properly applied for comparison of means. Statistical significance was defined at P < Results Seventy patients diagnosed with acne vulgaris by a dermatologist were included in this study. Twenty-eight (40%) of the patients were males and 42 (60%) females. The age of patients ranged from 16 to 34 years (mean ± SD, ± 4.62). As to occupation, most of patients were university or high-school students (29 = 41.4%), and some were clerks (16 = 22.85%), whereas the others were housewives (6 = 8.6%), farmers (3 = 4.3%), or unemployed (16 = 22.85%) SF-36. Thescoresforphysicalfunctioning,socialfunctioning, and bodily pain domains in patients were over 70%, butthescoresforrolephysical,generalhealth,vitality,role emotional and mental health in patients were under 70% (Table 1). After comparing mean score of QOL (SF-36) with respect to gender, the difference between men s scores and women s scores was found but it was not statistically significant (P = 0.70)(Table1). ComparingmeantotalscoreofQOL(SF-36)inregard to age using Tukey ranged test and ANOVA indicated that the mean score was different in different age groups but the difference was not significant. (ANOVA, P = 0.780)(Table2) DLQI. Scores on the DLQI in patients with acne vulgaris ranged from 0 to 22 (mean ± SD, 8.18 ± 4.83). The mean

3 Dermatology Research and Practice 3 Table 2: Comparison of mean score of QOL (SF36) in different domains in patients with acne vulgaris with respect to age using ANOVA. Domains < >30 Mean ± std. deviation Mean ± std. deviation Mean ± std. deviation P value PF ± ± ± RP ± ± ± RE ± ± ± VT ± ± ± MH ± ± ± SF ± ± ± BP ± ± ± GH ± ± ± Total ± ± ± Physical functioning (PF); role physical (RP); role emotional (RE); Vitality (VT); mental health (MH); social functioning (SF); bodily pain (BP); general health (GH). Table 3: Comparison of mean score of DLQI in patients with acne vulgaris regard to age using ANOVA. Age Mean Std. deviation P value < > scores of DLQI in male and female were 8.75 (±4.71) and 7.93 (±4.91), which was not statistically significant (t = 0.697, df =68, P = 0.488). The mean score of DLQI in regard to age was distinct in different age groups, but the difference was not significant. (P = 0.51)(Table3). Pearson s correlation coefficient test revealed that there was a reverse and significant correlation between all the domains of QOL in SF-36 questionnaire and the obtained scores from DLQI questionnaire. In other words, the higher theqolscoreinanyofthedimensions(sf-36),thelower thedlqiscoreandviceversa(table4). 4. Discussion Acne vulgaris is a very frequent skin disease that mostly involves adults both physically and emotionally, while it can also influence individuals in any age [12, 15, 21]. Acne has remarkable effect on self image and influences health-related quality of life (HRQL) [2, 19, 20, 22, 36] (Table 5) SF-36. Our findings somewhat correlate with other studies evaluating acne patients quality of life [12, 20, 22, 23, 37]. Al Robaee found that for recorded scores physical functioning, role physical, role emotional, and vitality dimension (SF-36) in patients with acne vulgaris were under 60% [12]. In some of previous studies, there was not a clear-cut correlation between life quality score and gender [22], and it agrees with our finding. But this is not in accordance with what Al Robaee found that female patients with acne were more probably to express better general health than males [12]. This difference seen between our finding and Al Robaee s might be due to cultural or socioeconomic differences. On the other hand, Tan et al. showed that greater effect on life quality was related with older age, female sex [5]. This difference seen between our finding and the Tan et al. one can be due to their study limitations as they reported (include (1) patients with acne were referred from the other centers, no first hand patients, (2) the limitation of final result values to facial acne) DLQI. The mean DLQI score in the patients of this study is higher compared to that in the studies by Takahashi et al. (mean DLQI = 3.99) in Japan (Tokyo) [23]. This difference seen between the result of the present study and other study can be due to cultural or socioeconomic differences. Generally, in most of previous studies, there was not a correlation between DLQI score and gender [14, 23] which is consistent with our finding. But these results disagree with Abdel-Hafez et al. [7] who found a correlation between DLQI score and gender. They reported that mean DLQI scores of male with acne are higher than those of female patients [7]. This result disagrees with our result. This difference seen between the result of the present study and other study can be due to duration and severity of acne differences. Comparing mean score of DLQI in regard to age in our study is in accordinate with the finding by Takahashi et al. [23] but disagrees with Lasek et al. They performed the study in USA and found that patients aged 40 years or older expressed greater impacts of their acne on their life quality than junior patients [24]. The difference seen between our finding and other study can be due to older age of their patients (mean age ± SD was 31 ± 10.1 years) Relationship between Acne s Quality of Life and Treatment. Recent results recommended that the treatment strategies to reduce the number and size of lesions of acne vulgaris can improve their life quality [16 18, 25 27, 36, 38]. Ammad et al. studied the employment of intense blue light with spectrum ranging nm (peak 420 nm) in the treatment of acne vulgaris. Significant improvement was obtained in the DLQI after the treatment [38].

4 4 Dermatology Research and Practice Table 4: Pearson correlation between the scores of different domains of QOL obtained from the two questionnaires (SF-36 and DLQI) in patients with acne vulgaris. PF RP RE VT MH SF BP GH Total r = 0.20 r = 0.37 r = 0.49 r = 0.36 r = 0.19 r = 0.21 r = 0.31 r = 0.38 r = 0.46 DLQI P = 0.10 P = P = P = P = 0.11 P = 0.09 P = P = P = Physical functioning (PF); role physical (RP); role emotional (RE); vitality (VT); mental health (MH); social functioning (SF); bodily pain (BP); general health (GH). Table 5: The summary of previous studies that looked at QOL in acne. Author Questionnaire Year Country Reference Tan et al. SF Japan [5] Abdel-Hafez et al. DLQI 2009 Egypt [7] Al Robaee SF Saudi Arabia [12] Kaymak et al. DLQI 2009 Palestine [16] Kobayashi et al. DLQI & kindex-29-j 2009 Japan [18] Arslan et al. SF Turkey [20] Do et al. The Self Image & Rosenberg Self-Esteem 2009 Korea [21] Mallon et al. Rosenberg Self-Esteem & General Health & DLQI & SF UK [22] Takahashi et al. DLQI 2006 Japan [23] Lasek and Chren DLQI 1998 USA [24] Jones-Caballero et al. Skindex Spain [25] Matsuoka et al. WHOQOL26 & DLQI 2006 Japan [26] Fried and Nighland Acne Quality of Life Index 2009 USA [27] Dréno Reviews the different scales 2006 France [28] Jones-Caballero et al. Skindex Spain [29] Lott et al. Review 2010 USA [30] Matsuoka et al. showed that directions on the usage of skin care and cosmetics for female patients with acne did not worsen acne treatment and affected patients life quality effectively. They suggested program for using skin care and cosmetics supplement traditional medical therapeutics for acne [26]. Fried and Nighland found that prescription of tretinoin gel microsphere in acne vulgaris patients resulted in a significant increase in both life quality and patient satisfaction [27]. Kobayashietal.foundthatroxithromycinhasatherapeutic effect on inflammatory acne and leads to enhancement of life quality in the patients [18]. Hahm et al. indicated that oral administration of isotretinoin in patients with acne vulgaris relieved symptoms of depression which was mostly related to acne-related lifequalityenhancementsratherthantoimprovementin acne grade [39]. Besides, Niemeier et al. suggested that dermatologistsshouldhavesomeknowledgeofthebasicsof psychotherapy and psychopharmacology, which sometimes must be combined with systemic and topical treatment of acne in conjunction with basic psychosomatic treatment [17]. Onthehand,adherencetotreatmentisanimportant issue in dermatology [28, 29]. Poor designed program in treatment sequel may be a popular reason of treatment failure in patients with acne [30]. Jones-Caballero et al. stated that dermatologists should clarify that following and support in treatment sequels directly related to the better results and better life quality [29]. Lott et al. found a positive correlation between life quality of patients with acne and obedience in treatment. The reason for this failure in treatment has been reported to be shortened time of the patients in a daily life [30]. Based on these findings, dermatologists should consider medication adherence as an important factor in further dermatologic investigations. Regarding the findings of related studies in this issue, it seems more advisable that psychiatric consult or psychotherapy may also be included in the treatment of severe acne vulgaris. Besides, to promote patients satisfaction and their quality of life, the following points are recommended. (1) Setting up supportive groups to patients in the specialized dermatology departments and hospitals. (2) Forming consultation and psychotherapy centers for patients with severe acne vulgaris. (3) Dermatologists should consider the impact of acne vulgaris on health-related quality of life and educate patients on possible treatments.

5 Dermatology Research and Practice 5 (4) Dermatologists should consider an early and effective therapy especially in patients with severe acne vulgaris to better medication adherence. 5. Limitation Limitation in our study was that all patients had referred to the clinic; thus, we do not know what impact acne has on QOLinpeoplewithacnewhodonotchoosetoorcannot come to the doctor. 6. Conclusion Acne vulgaris has a significant effect on the quality of life. There was not any significant gender or age related difference in QOL. Conflict of Interests The authors declare that they have no conflict of interests. Acknowledgments The authors wish to thank Dr. Mona Moshref, Dr. Javad Sharbaf, and all participants without whose help this study could not have been completed. This research was supported by Department of Research Grant in Birjand University of Medical Sciences. The authors also would like to acknowledge Research Deputy of Shiraz Dental School for their excellent choosing of Dr. Shahram Hamedani who graciously helped us in editing the English structure of the paper. References [1] A. Potocka, K. Turczyn-Jabloñska, and D. Merecz, Psychological correlates of quality of life in dermatology patients: the role of mental health and self-acceptance, Acta Dermatovenerologica Alpina, Pannonica et Adriatica,vol.18,no.2,pp.53 62,2009. [2]Y.Higaki,I.Watanabe,T.Masakietal., Japaneseversionof cutaneous body image scale: translation and validation, Journal of Dermatology,vol.36,no.9,pp ,2009. [3] L. Misery, A. Y. Finlay, N. Martin et al., Atopic dermatitis: impact on the quality of life of patients and their partners, Dermatology,vol.215,no.2,pp ,2007. [4] A. K. Wahl, C. Mørk, B. Mørk Lillehol et al., Changes in quality of life in persons with eczema and psoriasis after treatment in Departments of Dermatology, Acta Dermato-Venereologica, vol. 86, no. 3, pp , [5] J.K.L.Tan,Y.Li,K.Fungetal., Divergenceofdemographic factors associated with clinical severity compared with quality of life impact in acne, Cutaneous Medicine and Surgery, vol. 12, no. 5, pp , [6] A. Taylor, M. Pawaskar, S. L. Taylor, R. Balkrishnan, and S. R. Feldman, Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study, Journal of Cosmetic Dermatology,vol.7,no.3,pp ,2008. [7] K. Abdel-Hafez, A. M. Mahran, E. R. M. Hofny, K. A. Mohammed,A.M.Darweesh,andA.A.Aal, Theimpactof acne vulgaris on the quality of life and psychologic status in patients from upper Egypt, International Dermatology,vol.48,no.3,pp ,2009. [8] R. S. Cvetkovski, R. Zachariae, H. Jensen, J. Olsen, J. D. Johansen, and T. Agner, Quality of life and depression in a population of occupational hand eczema patients, Contact Dermatitis, vol. 54, no. 2, pp , [9] S. Aghaei, M. Sodaifi, P. Jafari, N. Mazharinia, and A. Y. Finlay, DLQ1 scores in vitiligo: reliability and validity of the Persian version, BMC Dermatology, vol. 4, article8,2004. [10] M. K. A. Basra, R. Fenech, R. M. Gatt, M. S. Salek, and A. Y. Finlay, The Dermatology Life Quality Index : a comprehensive review of validation data and clinical results, British Dermatology, vol.159,no.5,pp , [11] S. Öztürkcan, A. T. Ermertcan, E. Eser, and M. Turhan Şahin, Cross validation of the Turkish version of dermatology life quality index, International Dermatology, vol. 45, no. 11, pp , [12] A. A. Al Robaee, Assessment of general health and quality of life inpatients with acne using a validated generic questionnaire, Acta Dermatovenerologica Alpina, Pannonica et Adriatica, vol. 18,no.4,pp ,2009. [13] M.W.B.Ludwig,M.D.S.Oliveira,M.C.Muller,andJ.F.D.De Moraes, Quality of life and site of the lesion in dermatological patients, Anais Brasileiros de Dermatologia, vol.84,no.2,pp , [14] A. Y. Finlay and G. K. Khan, Dermatology Life Quality Index (DLQI) a simple practical measure for routine clinical use, Clinical and Experimental Dermatology, vol.19,no.3,pp , [15] E. Uhlenhake, B. A. Yentzer, and S. R. Feldman, Acne vulgaris and depression: a retrospective examination, Cosmetic Dermatology,vol.9,no.1,pp.59 63,2010. [16] Y. Kaymak, E. Taner, and Y. Taner, Comparison of depression, anxiety and life quality in acne vulgaris patients who were treated with either isotretinoin or topical agents, International Dermatology,vol.48,no.1,pp.41 46,2009. [17] V. Niemeier, J. Kupfer, and U. Gieler, Acne vulgaris psychosomatic aspects, the German Society of Dermatology, vol.4,no.12,pp ,2006. [18] M. Kobayashi, K. Kabashima, M. Nakamura, and Y. Tokura, Effects of oral antibiotic roxithromycin on quality of life in acne patients, Dermatology, vol. 36, no. 7, pp , [19]S.Caruso,S.Rugolo,C.Agnello,M.Romano,andA.Cianci, Quality of sexual life in hyperandrogenic women treated with an oral contraceptive containing chlormadinone acetate, JournalofSexualMedicine,vol.6,no.12,pp ,2009. [20] G. Arslan, U. Ayranci, A. Unsal, and D. Arslantas, Prevalence of depression, its correlates among students, and its effect on health-related quality of life in a Turkish university, Upsala Medical Sciences,vol.114,no.3,pp ,2009. [21] J. E. Do, S.-M. Cho, S.-I. In, K.-Y. Lim, S. Lee, and E.-S. Lee, Psychosocial aspects of acne vulgaris: a community-based study with Korean adolescents, Annals of Dermatology,vol.21, no. 2, pp , [22] E. Mallon, J. N. Newton, A. Klassen, S. L. Stewart-Brown, T. J. Ryan, and A. Y. Finlay, The quality of life in acne: a comparison with general medical conditions using generic questionnaires, British Dermatology,vol.140,no.4,pp ,1999.

6 6 Dermatology Research and Practice [23] N. Takahashi, Y. Suzukamo, M. Nakamura et al., Japanese version of the Dermatology Life Quality Index: validity and reliability in patients with acne, Health and Quality of Life Outcomes,vol.4,article46,2006. [24] R. J. Lasek and M.-M. Chren, Acne vulgaris and the quality of life of adult dermatology patients, Archives of Dermatology, vol. 134, no. 4, pp , [25] M. Jones-Caballero, M. M. Chren, B. Soler, E. Pedrosa, and P. F. Peñas, Quality of life in mild to moderate acne: relationship to clinical severity and factors influencing change with treatment, the European Academy of Dermatology and Venereology,vol.21,no.2,pp ,2007. [26] Y. Matsuoka, K. Yoneda, C. Sadahira, J. Katsuura, T. Moriue, and Y. Kubota, Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris, Dermatology, vol. 33, no. 11, pp , [27] R. Fried and M. Nighland, Acne quality of life and patient satisfaction following treatment with tretinoin pump, Journal of Drugs in Dermatology,vol.8,no.12,pp ,2009. [28] B. Dŕeno, Assessing quality of life in patients with acne vulgaris: implications for treatment, American Clinical Dermatology,vol.7,no.2,pp ,2006. [29] M. Jones-Caballero, E. Pedrosa, and P. F. Peñas, Self-reported adherence to treatment and quality of life in mild to moderate acne, Dermatology,vol.217,no.4,pp ,2008. [30]R.Lott,S.L.Taylor,J.L.O Neill,D.P.Krowchuk,andS. R. Feldman, Medication adherence among acne patients: a review, Cosmetic Dermatology,vol.9,no.2,pp , [31] M. Salamon, J. Chodkiewicz, A. Sysa-Jedrzejowska, and A. Wozniacka, Quality of life in patients with rosacea, Przegļd Lekarski,vol.65,no.9,pp ,2008. [32] N. Motamed, A. R. Ayatollahi, N. Zare, and A. Sadeghi- Hassanabadi, Validity and reliability of the Persian translation of the SF-36 version 2 questionnaire, Eastern Mediterranean Health Journal,vol.11,no.3,pp ,2005. [33] A. Montazeri, A. Goshtasebi, M. Vahdaninia, and B. Gandek, The Short Form Health Survey (SF-36): translation and validation study of the Iranian version, Quality of Life Research, vol. 14, no. 3, pp , [34] H. Jafari, S. Lahsaeizadeh, P. Jafari, and M. Karimi, Quality of life in thalassemia major: reliability and validity of the Persian version of the SF-36 questionnaire, Postgraduate Medicine,vol.54,no.4,pp ,2008. [35] J. E. Ware and M. Kosinski, Interpreting SF-36 summary health measures: a response, Quality of Life Research,vol.10,no.5,pp , [36] M. A. Radtke, I. Schäfer, and M. Augustin, Pharmacoeconomy in acne evaluation of benefit and economics, Journal der Deutschen Dermatologischen Gesellschaft, vol.8,suppl1,pp. S105 S114, [37] Z. Demircay, D. Seckin, A. Senol, and F. Demir, Patient s perspective: an important issue not to be overlooked in assessing acne severity, European Dermatology, vol. 18, no. 2, pp , [38] S.Ammad,M.Gonzales,C.Edwards,A.Y.Finlay,andC.Mills, An assessment of the efficacy of blue light phototherapy in the treatment of acne vulgaris, Cosmetic Dermatology, vol. 7, no. 3, pp , [39] B. J. Hahm, S. U. Min, M. Y. Yoon et al., Changes of psychiatric parameters and their relationships by oral isotretinoin in acne patients, JournalofDermatology,vol.36,no.5,pp , 2009.

7 MEDIATORS of INFLAMMATION The Scientific World Journal Gastroenterology Research and Practice Diabetes Research International Endocrinology Immunology Research Disease Markers Submit your manuscripts at BioMed Research International PPAR Research Obesity Ophthalmology Evidence-Based Complementary and Alternative Medicine Stem Cells International Oncology Parkinson s Disease Computational and Mathematical Methods in Medicine AIDS Behavioural Neurology Research and Treatment Oxidative Medicine and Cellular Longevity